Provider Demographics
NPI:1013304054
Name:MOORE, KENNETH ADAM (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ADAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST STE 5100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2274
Practice Address - Country:US
Practice Address - Phone:317-963-1300
Practice Address - Fax:317-222-2012
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN65489207T00000X
IN01090436A207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ043273Medicaid
IN300077297Medicaid
IN068010906OtherMEDICARE PTAN